Knowledge, attitudes, and practices (KAP) toward seasonal influenza vaccine among college students under the COVID‐19 pandemic in South China

Abstract Background The control measures of the coronavirus disease 2019 (COVID‐19) pandemic had influenced the activity of the influenza virus, and we were wondering the knowledge, attitudes, and practices (KAP) toward seasonal influenza vaccine among college students were having at the context of the COVID‐19 pandemic. Methods Online questionnaire survey of the college students was conducted and the data was collected anonymously, cross‐sectional study were used to describe the distribution of the KAP. Results There were 815 respondents in our study. Most participants have a high recognition of the effectiveness and safety of the influenza vaccine. However, a low awareness rate of influenza vaccine knowledge and vaccination rate (18%) against influenza was observed among college students. The education level and major would have a higher weight on the influence of KAP among the college students. Binary logistic regression analysis showed that the sex (OR = 2.163, p < .001), age (OR = 2.242, p < .001), heard of the influenza vaccine (OR = 2.655, p = .014), and “How necessary do you think vaccinating every year is?” (OR = 3.947, p < .001) of the college students were the main factors that affect the KAP on influenza vaccination. Conclusions Our study provided an insight into the KAP of influenza vaccine among college students in South China. The vaccination rate and acceptability of influenza vaccine in college students are higher than that in the whole population.


| BACKGROUND
][7][8] However, vaccination coverage remains low in developing countries, 3 which is far lower than 75% of the target populations recommended by World Health Organization (WHO). 9It's critical that herd immunity protects vulnerable populations and controls the pandemic. 10Vaccine hesitation is one of the most obstacles contributing to vaccine uptake and achievement of herd immunity, 9 vaccination hesitation is to refuse or postpone vaccination which is a worldwide phenomenon that undermines global public health. 11The reasons for WHO's vaccine hesitation are classified into three aspects: confidence, complacency, and convenience, namely the "3Cs" model: confidence refers to the confidence of vaccinators in the safety and effectiveness of vaccines, health system and vaccinators, and decisionmakers, complacency refers to the psychology that people think that the risk of vaccine-preventable diseases is low, and ignores the necessity of vaccination, convenience refers to the accessibility of vaccination, the acceptability of price, and so forth. 12It may be influenced by education levels, income, age, and so on. 9,13ollege students are a unique demographic group, which are well-educated, and the group had a crowded living environment and study places, what's more, frequent social activities are the typical characteristics of the population, which all lead to a higher risk of infection of IVs. 14 The outbreak of influenza in a campus would undermine the regular teaching activities and students' academic performance.Furthermore, college students are one of the most active populations, in terms of social activities which may cause widespread of influenza. 15Understanding the willingness of influenza vaccination among college students is crucial for influenza prevention and control.There are few studies published on Chinese college students' vaccine hesitancy, especially during the pandemic of COVID-19.Moreover, there were few surveys on the college students' vaccine hesitation founded and could be referred for the existing twindemic of influenza and COVID-19. 16s a result, we conducted a survey among college students in Guangzhou, China, including knowledge, attitudes, and practices (KAP), 17 to investigate the willingness of college students to hesitate and resist the possible factors in the current vaccination process, and to focus on college students in the current vaccination process to prepare for the expansion of immunization coverage in China, and to give better evidence of effective vaccination strategies in China.

| Participant selection
We conducted a cross-sectional survey during January 2021.The participants of this study need to meet the conditions as follows 1 : University Student in Guangzhou 2 ; volunteering to participate in the study 3 ; using a smartphone to fill the questionnaire.And the exclusion criteria 1 : Unfinished questionnaire 2 ; fill in the questionnaire in less than 2 min or more than 10 min.

| Data collection and quality management
Ethical and anonymous data use statements were declared at the first beginning of the questionnaire and agreed by the expectants.To ensure the validity of the questionnaire, a pretest was carried out.Finally, the questionnaire consisted of four parts, including 1 : demographic data 2 ; knowledge of the influenza vaccine 3 ; attitude toward the influenza vaccine 4 ; influenza vaccine practices.Closed-ended or multiple-choice were utilized in all questions.

| Knowledge
There are three questions about the knowledge.The first one is "What population needs the influenza vaccine?."And the answer consisted of five choices, including: Children (6 months to 5 years old); elderly people (>60 years); chronic disease patients; medical staff; and those who work with babies and children.The second is "When are recommended for influenza vaccination?."The answer choices are as follows: January to March; April to June; July to September; October to December; do not know.The third is "How necessary do you think vaccinating every year is?"The answers were: necessary, not necessary, and do not know.The first two topics are multiple-choice questions, and the last one is a single-choice question.

| Attitudes
The participants' attitudes toward the influenza were made up of five questions.Including 1 : Do you worry about getting influenza?, 2 Have you ever heard of the influenza vaccine?, 3 Do you think the influenza vaccine can protect you from getting influenza?, 4 How safe do you think the influenza vaccine is?, 4 and Will you advise your family and friends to be vaccinated with the influenza vaccine?All details were shown in Table 2.

| Practices
The questions following were utilized to evaluate the practices toward the influenza vaccine in the study.
The first question was "Have you been vaccinated with the influenza vaccine within the past 4 years?" and the answers were "Yes" or "No" While the participant answered "Yes" you need to report the frequency of influenza vaccination, the approach that led you to be vaccinated with the influenza vaccine and continue willingness to vaccinate.When the participants indicated their willingness to vaccinate or not and then reasons need to report.

| Data analysis
Excel was utilized to collect the data and put it in order.SPSS 18.0 was used to analyze the data.The χ 2 test and/ or Fisher's exact test were used to compare the proportions of groups with different ages, family incomes, and educational levels.To make the relationships between willingness to knowledge, attitude, and practice sense, the multivariate logistic was used.The odds ratios (ORs) were utilized to confirm the independent prediction factor.

| Demographics
There is a total of 815 college students participated in the survey, and 815 questionnaires data are valid.The male (N = 358, 43.9%) participated in the survey are less than female (N = 457, 56.1%).The median age of participants is 20.And the group of age 18−20 years old is the main group (N = 359, 44.1%).Most of the involved participants are in their first-year college (N = 413, 50.7%).Medicine is the main major of these college students (N = 566, 69.5%), the major ranked second is engineer (N = 194, 23.8%), and the last is science or other (N = 55, 6.8%).Per capita monthly income in family ranged from <1000 to 50,001 Yuan.Most of their income are less than 10,000 Yuan.Moreover, the overall result can be seen in Table 1.

| Knowledge
In this study, the awareness rate of influenza vaccine knowledge among college students was low.Most of the participants deem children (N = 689, 85.6%) and elderly people (N = 650, 79.8%) were influenza vaccine needing populations.And followed by medical staff (N = 567, 69.6%), those who worked with babies and children (N = 543, 66.6%), and chronic disease patients (N = 430, 52.8%).However, only a few participants knew January to March (N = 253, 31%) and October to December (N = 153, 18.8%) were the vaccination-recommended seasons.There was nearly one-third of participants  thought that influenza vaccination was not necessary (N = 262, 32.1%).Unabridged data were shown in Table 2.In the group analysis, the results showed that the group which age >20 years old or had a master's degree may have greater knowledge of recommended population for influenza vaccination (p < .05).About the recommended season for influenza, the different groups of age, education, and major both showed significant differences.And more details were shown in Table 3.

| Attitudes
In terms of attitudes, most participants have a high recognition of the effectiveness and safety of the influenza vaccine.All related data are shown in Table 4.
In the group analysis, the different groups may have a different attitude.The different groups of age, education, and income have significant differences (p < .05).The results showed that higher education degree and the elder may relate to low concern about influenza infection.Then, about advising family or friends to get the vaccine or not, the group age, education, and major have significant differences (p < .05).The results are shown in Table 5.

| Practice
Table 6 lists the results of the participants' practice.Merely 18% of participants have been vaccinated within the past 4 years.In the group of people vaccinated before, we found that there is a small number of participants who have an annual vaccination (N = 44, 5.5%).Doctors' recommendation is the most approach that led to being vaccinated (N = 74, 9.1%).And the people who were vaccinated before will have a high willingness to vaccinate again in the future (N = 104, 70%).The main obstacle to not continuing to vaccinate is limited vaccination sites (N = 76, 9.3%).
In the group of people who did not vaccine within the past years, the majority of reasons for did not vaccinate are unknown vaccination sites (N = 253, 31%).Contrary to the people who were vaccinated before, most of them do not want to vaccinate the influenza vaccine in the future (N = 35.7%,43.8%).
As the group analysis results are shown in   The approach that led you to be vaccinated with the influenza vaccine Advised by doctor 46  However, our data was limited in the college students and limited samples, and second, our study used the convenience sampling so that some bias can't be diminished.
All in all, during the COVID-19 epidemic, we should further improve the KAP toward influenza vaccination, and targeted intervention measures for the obstacles to prevent our global health in the future.

2 p
PracticeHave you been vaccinated with the influenza vaccine within the past 4 you will not to continue to vaccinate (multiple choice)

Table 7
Attitudes toward the influenza vaccine among the study participants in Guangzhou (N = 815).Attitudes toward the influenza vaccine in the age, education, major, and income group analysis (N = 815).
, the different groups of age or major may influent theT A B L E 4 | 7 of 14 Practices toward the influenza vaccine among the study participants in Guangzhou (N = 815).Have you been vaccinated with the influenza vaccine within the past 4 years?Practices toward the influenza vaccine in the age, education, major, and income group analysis (N = 815).
T A B L E 6 < .05).The elder (age >20) had a lower vaccination rate while the group of medicine majors had more vaccination.Higher-income groups (>10,000) may have more concerned about the limited effect of the vaccine (p < .05).The group of engineering major showed high willingness to vaccinate in the future (p < .05).Then, we conducted a multivariate analysis to identify which factors affect the outcome of vaccination.The results are all shown in Table8.The table affects factors including sex, age, education, major, income, and three single-choice questions about "Have you ever heard of the influenza vaccine?," "Do you think the influenza vaccine can protect you from getting influenza?,""How necessary do you think vaccinating every year is?," "How safe do you think the influenza vaccine is?," and "Do you worry about getting influenza?."The sex and age are two significant influence factors (p < .01).Heard of the influenza vaccine (p = .014)and "How necessary do you think vaccinating every year is?" (p sig < 0.001).As a result, the significant results may affect the vaccination.Other results were not significant difference.Binary logistic regression analysis of the impact of various factors on the behavior of being vaccinated with the influenza vaccine within the past 4 year.
T A B L E 8